America the Beautiful - A Tragedy in Three Notes

************************************************Apparently there is nothing that cannot happen.- Mark Twain************************************************

Note #1: A Note From Jeff

I am never disappointed when I get a note from Jeff.

He is an old guy, and a feisty one. He is wiry in build. He has celebrated 83 birthdays and he is still going strong. His intellect far surpasses mine, even on the brightest day of my life when I am fully rested and loaded with caffeine. His wit is slicing, incisive, and precise. He tolerates neither fools nor foolishness. In a world abundantly populated with fools and foolishness, there is plenty for Jeff to say, and he is never reticent.

I am never disappointed when I get a note from Jeff.

As a young man, he was a successful scholar at one of America's oldest and most prestigious universities. He was an accomplished college athlete. He served in the military in the Korean War, where he was injured in combat; to this day, he carries shrapnel in his back, a source of chronic pain. [If you take a medical history, he will tell you that he was a victim of "acute lead poisoning" in the war.] He became a successful businessman and a leader in his community, and he is highly regarded by all who know him.

It is a joy to be in Jeff’s presence. He is distinguished in carriage, gentlemanly in manner, gracious in demeanor, a son of the Old South in the best sense of the term. He is a man of dignity and integrity. He expects to be treated with integrity and dignity and respect.

He would attribute his successes in life to his propensity for being meticulous, accurate, honest, and trustworthy. He has no tolerance for those who are unable to be meticulous, accurate, honest, or trustworthy. He is unyielding in his intolerance, and he cares not an iota whether the deficit is congenital or acquired. Sloppiness in matters of import is not acceptable.

Jeff has learned the hard way to be selective about his medical care. He is an expert in comparing doctors, clinics, hospitals, and emergency rooms. He has seen a good number of them in his day. I have had the pleasure of being a physician and a medical confidante for Jeff for over two decades. I contribute a little to his care, and I learn a lot. His journey to see me takes less than two hours. The distance is short enough to make it tolerable for him, and long enough to make it honorary for me.

Between visits, I get e-mails from Jeff for questions about his own healthcare. I receive handwritten notes when he has a topic of great substance to discuss.

[I am never disappointed when I get a note from Jeff.]

His latest missive is scrawled on a patriotic notepad. The top line proclaims “America the Beautiful” in an elegant script with Fourth-of-July red. The bottom of the page is festooned with gleaming white 5-sided stars on a dark blue sky. [It is a notepad most suitable for an American hero who put his own life on the line in service to his country.] Here is the note Jeff sent me…

Note #2: A Note by a Doctor

Jeff, it seems, had been suffering from abdominal pain for several days.

He traveled to a medical facility of high reputation, within striking distance of his home.

He arrived, and he was assessed. His symptoms defied explanation.

Undiagnosed, Jeff was sent back home to his primary care doctor for follow-up.

His primary care doctor reviewed the record of Jeff’s workup at the famous facility, and then initialed the note to document his review.

Jeff’s hometown doctor discovered an absurd statement in Jeff’s history.

Jeff was aghast. He asked his primary care doctor for a copy of the clinical note.

[Jeff had a purpose in mind.]

Jeff appended his “America the Beautiful” note to his medical evaluation, and he sent it to me.

[He suspected I wouldn’t just sit on it.]

And now, on behalf of Jeff, and on behalf of all of us, I present for your consideration a copy of the note that caused such ruckus.

It is a medical note, signed by a doctor.

Note #3: A Note of Consternation

The brave new world of the electronic medical record has generated an unanticipated consequence – the prolific generation of inaccuracies in the patient’s history. Rarely has the flaw been so wonderfully demonstrated as in Jeff’s medical record.

Physicians increasingly question the validity of the information in a patient’s record.

“The patient states that she believes she is currently not pregnant.”

We are starting to distrust the colleagues who write such things. How could we not?

Jeff’s example is not an isolated occurrence. Most clinicians regularly encounter medical record flaws similar to Jeff’s, or worse. The power of Jeff’s example is this – it is blatantly and unequivocally and unarguably a falsehood. It is a lie.

“The patient states that she believes she is currently not pregnant.”

No! No! No!She did not state that!She is not a “she.”“She” is Jeff, an 83-year-old man with belly pain, an articulate and highly educated man who does not tolerate fools or foolishness or dishonesty.

“The patient states that she believes she is currently not pregnant.”

Is there any reason why Jeff, finding that his own medical record contains “documentation” of a statement he never stated, should not conclude that its presence is the work of a fool, an example of foolishness, or the product of dishonesty? How does this influence Jeff’s trust in the doctor and in the medical facility that generated such folly? [For his answer, refer to his “America the Beautiful” note…]

There is a growing uneasy feeling within the medical community that the electronic medical record no longer serves as the reliable repository of a patient’s medical history it was intended to be. Usurped for other purposes, it is becoming a storehouse of elements of history that were not asked and elements of examinations that were never performed. The noise-to-signal ratio is deafening.

“The patient states that she believes she is currently not pregnant.”

Where did that even come from?

The sentence is not the independent work of a thoughtful physician. It is an example of computer-generated medical history, created by the unholy alliance of a distressed doctor in collusion with a machine. The physician bears the bulk of the responsibility for deferring to the computer to write the sentence, and for not discovering the absurdity before signing the document. What were the other variables that influenced the doctor to generate such a statement? Laziness? Greed? Fatigue? Inattention? Dishonesty? You and I will never know; we weren’t there. Who are we to judge another person?

We are allowed to judge a system that allows such things to happen. We must judge it.

We can probably agree on one thing. It is not a sentence a rational doctor would write spontaneously in the assessment of an 83-year-old man. It is a computer-generated lie, a flaw of the electronic medical record in its current design.

The computer dangled the pregnancy question in front of our ill-fated doctor. She had not asked about pregnancy, but she bit at the bait. One click of the mouse, one falsehood.

It does not require physician malevolence to create such a thing; all it requires is physician inattention.

The root of the problem comes from the melding of two independent activities. Taking the patient’s history in a thorough and accurate manner requires thought. Documenting the patient’s history in a lucid and coherent manner requires thought. These are two separate processes, each one requiring thought by the doctor.

In the name of “efficiency,” these two essential elements of medical care have become computer-driven and thoughtless events.

Physicians have been encouraged to let the computer guide the process of information gathering, and have been coerced into believing that selecting the right “macros” or “smart phrases” allows the computer to write a passable patient history with no effort by the doctor.

It becomes a mindless activity.The result?Exactly what you would expect from a mindless activity.

“The patient states that she believes she is currently not pregnant.”

The set-up is simple. The computer screen provides lists of symptoms with checkboxes. The doctor grabs a computer mouse, clicks a few boxes, and watches the selected words get plugged into prewritten sentences. It’s almost magic.

Type a few letters, and – voilà! – a whole prefabricated paragraph appears. Check boxes “yes” or “no,” and – kazaam! – another fully templated paragraph is created before our very eyes.

A computer can be programmed to list symptoms for any complaint imaginable. It can create a sentence for any question that was asked. Just click the box.

[It can create a sentence for any question that was not asked. Just click the box.]

How fast!How efficient!How monotonous.How empty of content.

Readable prose and understandable narrative are rapidly disappearing from the medical record. [Read Jeff’s record.] The computer’s sentences tend to be choppy. Some are nearly incoherent. The syntax comes straight out of an “English-as-a-second-language” class. The language is stilted and clumsy. [“The patient has had a change in bowel habit.”] The medical record is full of awkward phrasing, confused chronologies, and duplication of content. Random and unrelated statements are strung together. It violates every rule of effective communication we learned in third grade, much less the knowledge we gained in medical school.

As a result, the patient’s story is no longer a story.As a result, the patient is no longer a person.[How efficient…]

History-taking is much more than information gathering. History-taking requires thinking about symptoms and circumstances and pathophysiology. It requires a connection with the patient, an effort to understand the patient.

First you must seek the story from within the patient.Then you try to find the patient within the story.Then you think, and reflect, and ask some more.Then you record the story as accurately as you possibly can.

Read the doctor’s note on Jeff. Only two things are lacking.Jeff’s story is one of them.Jeff is the other one.

In one sense, Jeff’s flawed history is a relatively harmless one as far as medical record errors go. It has one huge saving grace: it is flamingly, preposterously, ridiculously absurd. Jeff can be done no harm by the declaration that “she” has declared pregnancy an unlikely possibility. The statement is ridiculous enough that it must be ignored. [Far more dangerous are the medical record falsehoods that are not as flagrant as this one, that may be believable enough to form the basis of clinical decisions.]

In another sense, though, Jeff’s flawed history is disastrously destructive. Jeff has judged the physician who signed the document to be a fool. The reputation of the doctor’s institution is irreparably tarnished. Why would a patient or another doctor or an insurance company or a jury believe anything in Jeff’s record?

As a profession, we should be ashamed that we got to this point.

And if we aren’t ashamed for ourselves, we should be aware that we have patients such as Jeff who are ashamed for us…and ashamed of us.

It is time for us to consider our actions.It is time for personal accountability.

It is time to practice medicine as though the patient has primacy over the computer.

This is serious business.

Postscript [The Closing Note]:

On March 20, Jeff sent me an e-mail with questions about an insulin dose adjustment. He concluded with the following medical update:

“Regarding my pregnancy - everything seems to be OK, except I am experiencing ‘morning sickness,’ but I'm sure it will go away after the 4th or 5th month. Will let you know whether it's a girl or boy - maybe twins. I am thankful for the wonderful experience provided by [medical facility].”

******************************************************Always do right; this will gratify some people and astonish the rest.- Mark Twain******************************************************

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